Infection Control (EHC)

• Conducted on

  Date

• Prepared by

• Location
  Address

• Screener is present at the entrance of the facility

  Yes

  No

  N/A

• Screener has appropriate PPE worn (e.g. surgical mask is worn properly)

  Yes

  No

  N/A

• Patients were observed to be screened properly with infrared thermometer

  Yes

  No

  N/A

• Tape/Markers are intact and visible for patients to see

  Yes

  No

  N/A

Appointment Check in Area

• Desks during check - in are clean and clear of unnecessary items?

  Yes

  No

  N/A

• Employees have surgical masks properly worn?

  Yes

  No

  N/A

• Employees are observed to be performing hand hygiene and do not have gloves worn during patient interaction

  Yes

  No

  N/A

• Payment transactions occur one way - meaning the employee is not touching debit cards and giving it back to patient

  Yes

  No

  N/A

Waiting Area

• There are less than 5 people in the waiting area

  Yes

  No

  N/A

• All patients are displaying appropriate social distancing (more than 6 ft) apart. This may exclude Parent/Child/Caregivers

  Yes

  No

  N/A

• Patients have masks or a face covering worn

  Yes

  No

  N/A

Clinic - Break Room - Pit Area

• Hand sanitizers are appropriately stocked inside and outside exam rooms

  Yes

  No

  N/A

• PPE is properly stocked and available for health care personnel use

  Yes

  No

  N/A

• Exam room appears to be clean and ready for patient use

  Yes

  No

  N/A

• Staff is appropriately using surgical masks during shift

  Yes

  No

  N/A

• Healthcare providers have surgical masks and eye protection worn during visit with patient

  Yes

  No

  N/A

• Staff is observed to perform hand hygiene prior to entering and leaving patients room

  Yes

  No

  N/A

• Pit/Work area is clean and presentable (If there is open food in the pit area please put 'no')

  Yes

  No

  N/A

Exiting the Facility

• There is no overcrowding of patients as they exit the premises.

  Yes

  No

  N/A

• The hazardous waste storage rooms are closed and properly secured

  Yes

  No

  N/A

• Exiting appears safe with no object blocking the hallways and exiting pathways

  Yes

  No

  N/A